Tough Times in the Emergency Department. St.Emlyn’s


Times are tough in the Emergency Department.

Is your ED seeing an unprecedented number of patients lately?

Do you feel like you are under excessive pressure because of this?

Do you recently feel low as a result?

Maybe you’ve even thought that EM is not for you anymore and considered leaving your specialty (SACRILEGE!) [Ed – it’s ok, we all have days like that]

Try the following tips to boost your morale and that of your team, even in these tough times.


Disclaimer: the following tips are not necessarily based on evidence. These are things I have picked up during my short time as a humble emergency physician in a large, busy city centre ED. I hope you might find them useful and maybe even select something to take home with you…

Practice gratitude

In this fast-paced crazy word we often forget to use a very simple way of expressing our appreciation: saying thank you. Say it ad nauseam, feel free to add “so much” and combine it with the recipient’s first name if possible. This last point can be tricky if you work in a big centre with hundreds of professionals, like I do. It is difficult to remember everyone’s first name (let alone how to pronounce it) and I have to use all sorts of tricks to try to decipher first names on ID badges hanging on lanyards. But practicalities aside, would you not raise your sore, heavy head from writing your notes if someone from the team said to you: “thank you so much for coming down to the ED to help with this challenging case, Janos”? This builds good rapport with your multi-discplinary team,  builds resilience and let’s be honest, it is pure courtesy you will have learned from your mama!

Help others

You are more likely to get help from others if you help out too. People will remember a small favour you did for them (like helping with a difficult cannulation or taking those notes to reception on your way to the coffee room) when you ask for another one in return. Cliff Reid talks about this (amongst other things) in his excellent SMACC talk “Making Things Happen”. If you have not seen/listened to this talk yet, I suggest you do so.

There is no fixed currency exchange here: you are likely to get a bigger favour back than the original one. It is simple psychology but it’s also good for your soul!

Practice smiling and say good morning

It is so much more pleasant to work with someone who smiles than someone with a grumpy face! It is well-known that smiling and a good mood are contagious. I like to say a loud “good morning!” as I walk through the department before I reach my office. Do not forget to include non-clinical staff into this habit. Our domestic staff, for example, always seem surprised when I walk in with a smile and loudly greet them! They are part of the team but I suspect they often feel forgotten and undervalued in the big hierarchy of our healthcare system. Associate your smile with a bit of good humour and you will be the star everyone wants to work with. Patients will also appreciate and remember that compassionate smiling face (caveat here: use it appropriately), staff are more likely to help you out with unpopular tasks and you will boost your own morale. If you don’t feel like smiling, try this (as recommended by EM legend Steve Jones): hold a pen or pencil between your teeth for two minutes. You’ll find smiling much more natural afterwards. Works best if there are a group of you doing it at once!

If you struggle to stay positive, try getting into the habit of reflecting on Three Good Things each day (more info from Rob Orman at ERCast here).

Share your mental model

This is discussed and taught at lengths at various resuscitation courses nowadays. Prepare your resuscitation room, prepare your equipment, run through the options before your critically ill patient arrives. It’s not rocket science: the patient will get the care they need if you have planned ahead whereas unprepared teams result in poorer outcome both for the patient and the team. Remember the old adage “failing to plan is planning to fail”?

This however works for non-critically ill/injured patients too, so make sure you verbalise your plan even outside your resus room. Most of the complaints we receive are results of poor or nonexistent communication between staff and patients. People talk about shared decision-making but I would like to think this is simple good communication. “Mr Brown, I am planning to perform a chest x-ray with your consent and if this shows signs of an infection, we might well need to admit you into hospital”. This might sound excessive to some but I would argue that it is simply spelling out a potentially complex process to a patient who might not be familiar with your plan/the system and by doing so we can cover all aspects of shared decision making.

Use alternative ways of asking 

Difficult referrals occur on a daily basis in our specialty and are a source of frustration for junior and senior staff alike. There is nothing more frustrating than “having to sell that referral” and this can occur for a variety of reasons. The most common reason for conflicts, however, is that the mental model I talked about above is not shared in an effective manner so that the colleague taking your referral does not necessarily share or understand your perceived need for the admission.

Most referrals nowadays happen via phone or another similar communication device making that valuable face-to-face contact disappear. The emphasis is on the verbal component of the process and words are worth gold here. Instead of shyly saying “I would like to refer Mr Brown for admission because of a fall”, try to expand on your reasons for referral/request for admission. Try something like, “I was hoping you could review Mr Brown because of a recent fall. He lives alone at home, has poor mobility and visual impairment due to cataracts. I am worried that he will not be able to cope at home alone and is therefore at risks of further falls. I think he would benefit from the excellent service your team provides”. Flattering but more likely to be effective…

Cliff Reid discusses this too in the above-mentioned talk.

Practice emotional intelligence

My colleague Rick Body recently spoke about this at the last RCEM conference in Liverpool. Emotional intelligence is an important concept for emergency physicians and is often overlooked or forgotten. It is the ability to control your emotions so you can be ‘hard’ and ‘objective’ in challenging cases, while later allowing yourself to express your emotions when it’s appropriate to do so – e.g. when talking to a patient’s family after a death. We are all different and react to emotions differently. There are people who tend to make jokes, while others are able to just carry on after ending a resuscitation, for example.

It isn’t that we don’t feel emotions but instead this is probably just our ‘barrier’, our way of shielding ourselves from the storm of our emotions. Rarely do we allow ourselves to show outwardly emotion as super-docs but there’s no doubt that our thoughts still continue for a short while after a difficult case. After discontinuing CPR, it’s very likely that some people are still thinking and processing, carrying emotional luggage that needs to be dealt with rather than suppressed. We are humans, not machines. Having emotions is characteristic of mankind: do not try to be a machine! So make an effort to discuss the clinical aspects of difficult cases during your debrief but also try to cover the emotions felt by your staff as well.

If you’re interested in knowing more about debrief, we recommend this excellent podcast at ERCast featuring our very own Ashley Liebig.

In summary

We do know that it is essential that we do not lose our cool during the management of a major incident or when leading a resuscitation team. This is evident.

I would however argue that it is equally important that we do not lose our cool even during our mundane tasks. I mean it is so much easier to be nice and pleasant than being a grumpy face. Just be nice and cool. In that order!  Try it…


Be good!

Your humble servant Janos

@baombejp on Twitter


Before you go please don’t forget to…

Cite this article as: Janos Baombe, "Tough Times in the Emergency Department. St.Emlyn’s," in St.Emlyn's, November 30, 2017,

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